
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"><html><head><META http-equiv="Content-Type" content="text/html; charset=utf-8"></head><body>
  
  
  <div>
<form name="0.1_contactform" method="post" action="http://send_form_email.php" target="_blank" onsubmit="return window.confirm(&quot;You are submitting information to an external page.\nAre you sure?&quot;);">
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<table width="450px">
<tr>
 <td valign="top" colspan="2">
     <b>Feedback Form</b></td>
</tr>
<tr>
 <td valign="top">
  <label>First Name *</label>
 </td>
 <td valign="top">
  <input type="text" name="first_name" maxlength="50" size="30">
 </td>
</tr>
<tr>
 <td valign="top">
  <label>Last Name *</label>
 </td>
 <td valign="top">
  <input type="text" name="last_name" maxlength="50" size="30">
 </td>
</tr>
<tr>
 <td valign="top">
  <label>Email Address *</label>
 </td>
 <td valign="top">
  <input type="text" name="email" maxlength="80" size="30">
 </td>
</tr>
<tr>
 <td valign="top">
  <label>Telephone Number</label>
 </td>
 <td valign="top">
  <input type="text" name="telephone" maxlength="30" size="30">
 </td>
</tr>
<tr>
 <td valign="top">
  <label>Comments *</label>
 </td>
 <td valign="top">
  <textarea name="comments" maxlength="1000" cols="25" rows="6"></textarea>
 </td>
</tr>
<tr>
 <td colspan="2" style="text-align:center">
  <input type="submit" value="Submit" style="width:127px">
</td></tr>
</table>
</form>
</div></body></html>
